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Nov 30, 2011

The psychological backlash against Hickie and McGorry

It’s not only psychologists at war over mental health reform -- considerable vitriol is also being directed at the country’s most prominent psychiatrists, Ian Hickie and Pat McGorry. Crikey's series on mental health reform continues.

Melissa Sweet

Health journalist and Croakey co-ordinator

After years of neglect the federal government has shovelled billions of dollars into the mental healthcare system — but the debate on how best to spend it has just begun. In the second of a four-part joint investigation with Inside Story, health journalist and Croakey blogger Melissa Sweet examines the vitriol directed at mental health campaigners Ian Hickie and Pat McGorry …

It’s not only psychologists who have been tearing each other to shreds (as outlined in part one of this series). Considerable vitriol is also being directed at two of the country’s most prominent psychiatrists, Ian Hickie, executive director of the Brain and Mind Research Institute at the University of Sydney, and Pat McGorry, an Australian of the Year and executive director of Orygen Youth Health in Melbourne, a mental health service that includes the Early Psychosis Prevention and Intervention Centre.

For years, Hickie and McGorry have worked closely as prominent advocates, not only calling for more funds for mental health but also pushing for changes to the way funders, services and professionals operate. They have argued for new types of services to meet the needs of young people, who often fall through the gap between child and adult services despite being at a stage of life at which many mental health problems develop. They have also stressed the importance of issues like education, employment and social inclusion.

Hickie and McGorry were instrumental in developing headspace, also known as the National Youth Mental Health Foundation, and are directors of the not-for-profit organisation. Headspace aims to provide comprehensive care to those aged 12 to 25 by bringing together specialist and primary health services to provide general health and mental health services, alcohol and drug counselling, and education, employment and other assistance.

That there is now tri-partisan support for mental health reform is at least partly a reflection of the pair’s sustained engagement with the media and politicians of all persuasions. Yet since the budget they have come under fire from a wide range of critics. They have been accused of having undue influence on policy, of feathering their own nests, of being in the pockets of the drug industry, and of failing to bring the wider sector with them. (It’s worth noting that the expansion of headspace and early psychosis intervention services was recommended in the 2009 National Health and Hospitals Reform Commission report and by the Mental Health Council of Australia.)

At least some of the ill-will is explained by the fact the Better Access program, of which Hickie in particular has been a longstanding critic, was cut while headspace and early psychosis intervention services will be expanded. Some see this as a case of the government converting former critics into supporters. Others note that one motivation for the Better Access changes was to support an expansion of a more equitable system of access to psychological care via the Access to Allied Psychological Services program. The pity, as the Senate report pointed out, is that these were not rolled out before the cuts took effect.

The attacks on Hickie and McGorry can be viewed through multiple prisms. They are tall poppies whose strong advocacy is bound to create professional jealousies. “It’s the peril of being a public health advocate,” says Wayne Hall, a professor in the Centre for Clinical Research at the University of Queensland. “You do get a high profile and there will be plenty of people to shoot you down. The only thing that surprises me, having been in the drug and alcohol field, is it’s taken so long for Pat and Ian to cop the criticism they have.”

The backlash against the pair also reflects professional demarcation disputes. Creating a new type of service for youth means stepping on the toes of existing child and adult services and service providers, for example, and some child psychiatrists view Hickie and McGorry as intruding on their turf. And there are inevitably tensions between prevention and early intervention and treatment, and between those focused on the needs of the patient in front of them versus those considering the broader population’s needs — including people unable to get access to existing services.

Then there are the tensions between those professionals who deal with less common but more severe disorders like schizophrenia and those advocating for less severe but more common disorders like depression and anxiety. There is also competition for funds between services and professionals focused on different stages of the lifespan. One of the more astute observations in the Senate report came from the Australian Counselling Association, which commented that “the problem is the siloing of professions. Every profession wants the dollar for their profession and every peak body wants the money for their members … Shouldn’t it be based on consumer need?”

But Louise Newman, professor of developmental psychiatry at Monash University, says competition for funding in different areas is not so much about professional infighting as a result of historic underfunding of mental health. “It’s the starving dogs with their bone,” says Newman, who argues for far greater focus on early childhood and family support. Or as another senior psychiatrist puts it: “It’s all about dividing a cake. Everything is at the expense of somebody else.”

Some of the frustration also reflects wider disappointment with health reform. So much more was promised than has been delivered — we are still left with fragmented funding and services — and so much remains unclear, especially about the future of community services and how mental health will fare under casemix funding for hospitals. There are also real questions about the logistics of the national roll-out of headspace and the early psychosis intervention centres, and whether funding, workforce, bureaucratic and federal/state political processes are up to the task.

And while Hickie has been critiquing the Better Access program, others have been raising questions about the evidence base for headspace and the Early Psychosis Prevention and Intervention Centre (EPPIC). One of those is Jon Jureidini, a child psychiatrist in Adelaide and member of Healthy Skepticism, an organisation that monitors inappropriate pharmaceutical marketing and influence. He argues the evidence supporting the approach taken by headspace and EPPIC has been over-sold, and he also raises broader questions about whether a medical response is appropriate for the many problems affecting young people that have social origins.

“This is not to say that headspace and EPPIC” — early psychosis intervention — “are without merit,” he says. “Both of these models warrant further exploration and evaluation but they certainly aren’t of the quality that we should give over the vast majority of the new money.” One of the reasons for divisions within mental health, Jureidini adds, is the lack of firm evidence about the merits of various interventions. “We’re working in an area of uncertainty. There’s very little concrete evidence to separate one person’s idea from another in terms of their effectiveness.”

John Mendoza, whose high-profile resignation last year as chair of the National Advisory Council on Mental Health has consigned him to the political sin bin, has a different perspective, expressing frustration at the preoccupation with the news services and corresponding lack of scrutiny of existing services. “Total federal and state mental health funding will come in at just under $6 billion in one year. This year we will spend $60 million on early intervention through EPPIC and headspace,” he says.“Our state governments will spend over $500 million on stand-alone psychiatric institutions,” Mendoza points out, “and we still have 2100 beds in such institutions. We’ve had pathetic governance around national mental health plans for 20 years. Everyone agreed we were closing these institutions in 1992. At the moment we are still spending on our acute care beds and our stand-alone beds over 50% of our total resources. They’re not well-based interventions. The acute care beds in general hospitals should make up about 10% of our general mental health investment.” The critics of early intervention, he says, “should focus on where the big problems are”.

No doubt the backlash against Hickie and McGorry also reflects broader community suspicion about psychiatry, perhaps not surprising given the profession’s history of attracting royal commissions and other inquiries. There are also concerns about medicalisation of health problems more generally — the inappropriate use of psychiatric medications is a genuine concern, particularly in nursing homes — and about overly close ties between the psychiatry profession and the pharmaceutical industry.

“Our college of psychiatry, among other medical and surgical colleges in Australia and elsewhere, became addicted to drug company money — not just for running conferences, but to meet the bottom line,” says Alan Rosen, a psychiatrist who has been a strong advocate for community mental health and works with the Brain and Mind Research Institute at the University of Sydney and the University of Wollongong. “They are at different stages of painfully weaning themselves off this formerly bountiful teat.”

Rosen says he generally supports the work of Healthy Skepticism, but thinks the focus by some members on Hickie and McGorry is misplaced, given the pair’s emphasis on a psycho-social model of health care and focus on social justice rather than narrowly clinical approaches. “In this case, I think Juredini et al are criticising a movement [early intervention into psychosis] that is actually trying to persuade other clinicians to lower anti-psychosis medication use to often very small dose levels, only if and when it is necessary,” he says.

McGorry himself says he has much in common with the broader concerns of Healthy Skepticism, having devoted much of his career to trying to reduce the adverse impact of medications, and the impact of traumatic systems of care on young people. “My whole career has been trying to reduce reliance on antipsychotic medications,” he says. “I’ve done most of my research on psychosocial treatments.”

The backlash against Hickie and McGorry is also being fed by the extreme end of the anti-psychiatry lobby, including scientologists who have been lodging freedom of information requests targeting their research projects at the universities of Melbourne and Sydney. The Citizens Commission on Human Rights, founded by scientologists in 1969 as a “mental health watchdog”, includes amongst its work a museum in its Hollywood headquarters called “Psychiatry: An Industry of Death”. The CCHR website says “this state-of-the-art museum documents how psychiatry is an industry driven by profit, its pretended help often resulting in death”.

Powerful personalities are another factor. The pair may have different personal styles — McGorry being a quiet, restrained presence in contrast to the voluble, high-energy Hickie — but they share an absolute faith in the rightness of their causes. They are “true believers”, say some colleagues. Years ago, Hickie’s mother told me that her son can be argumentative. She said: “If he thinks he’s right, heaven help you.”

It’s not surprising that when Hickie and McGorry loudly describe the failings of existing services, those working in these services, often under difficult circumstances, take affront. Indeed, it seems that the major protagonists in recent debates all feel, to some extent, that they have been victims of personal criticisms or slurs. Wayne Hall observes: “There’s an even-handedness in the personal attacks.”

For John Mendoza, the divisions reflect a sector in crisis: “This infighting is typical of a bottom dweller, dog-eat-dog world where there are so few resources that it breeds this sorts of behaviour. The only other area where you see these sort of divisions is in indigenous affairs.” Indeed, a cynic might think the post-budget schisms represent a convenient outcome for a government previously facing an effective united lobby with massive public support fanned by the activist group GetUp.

As another mental health policy insider puts it: “As far as the sector goes, we always used to bitch and complain but we did it behind closed doors. Now we’re having an open civil war. That just allows government to say, ‘they don’t know what to do, what the priorities are, they can’t agree. And if the experts can’t agree, then why should we throw public money at mental health?'”

Jennifer Doggett also sees the division as destructive: “I wouldn’t have thought there are going to be any winners from trying to discredit what [Hickie and McGorry] have done. A more constructive approach would be to say that these initiatives can achieve some gains and this is what else needs to be done.” Doggett says when groups ask for funding political advisors want to anticipate the likely political fallout. “You can never give them everything they ask for,” she says. “You ask, if we give them 80%, are we going to get beaten up for the 20% we don’t give them? If that’s the case, we may as well give the money elsewhere.”

For those who have followed the longer history of mental health reform, the personalisation of the backlash is not unusual. Over the years, many of those associated with challenges to the status quo have come under bitter attack. On occasions, these have escalated into personal threats and acts of intimidation and violence.

Dawn O’Neil (whose background in mental health is profiled in part one of this series) sees the backlash against Hickie and McGorry as in part a reflection of their role as change agents. “I know them both very well,” she says. “I have found them to be incredibly passionate, committed, smart and … I would call them revolutionaries really.”

*Tomorrow: Competing claims and interests in mental health debates

**Declarations: The Croakey health blog, which Melissa Sweet moderates, has received funding from the Brain and Mind Research Institute and the Public Health Association of Australia. The author has also been paid for research (not related to mental health) through the University of Melbourne centre involved in the Better Access evaluation, and the lead author of the evaluation, Jane Pirkis, was interviewed for this article.

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13 thoughts on “The psychological backlash against Hickie and McGorry

  1. shepherdmarilyn

    Where is the evidence for the backlash or the ideas even working.

    There is zero evidence in the world that psychosis is predictable and can be treated in advance.

    McGorry even wanted to do a study using drugs on healthy kids.

    Now what I have a problem with is everything being called a mental health disease when it is not.

    Anyone can be temporarily unhappy or distressed, that is not a mental health disorder and yet it is treated as if it is.

    My grand-daughter had a small break down last year and put her fist through the wall, she ended up in a psych hospital for a week. It did save here life but no-one predicted or saw that attack coming.

    Now she is a fine, happy, fit and well and working full time and the problem will probably never recur.

    Things happen, people should not be stigmatised for life because they break down like so many are.

    Yet my son who is nuts went undiagnosed until his late teens and was treated for years with drugs that made it worse.

    No-one noticed my son in law was schizophrenic until he stabbed a man in the back over a packet of cigarettes.

    I don’t much care about McGorry and Hickie but they don’t seem to have actually done anything much for the teenagers yet McGorry did good work with refugees we had driven insane.

  2. Just Me

    “One of the reasons for divisions within mental health, Jureidini adds, is the lack of firm evidence about the merits of various interventions. “We’re working in an area of uncertainty. There’s very little concrete evidence to separate one person’s idea from another in terms of their effectiveness.””

    This is the real problem, and what drives the bitter debate. Until psychiatry can come up with more insightful explanations (models), and more effective treatments (especially more accurate and objective measures of therapeutic outcome), then this debate will remain unresolved.

    Hickie in particular deserves some of the criticism he gets, as he is pushing the generic psycho-social model too hard, trying to make it fit where it really doesn’t. Bit too much of the partisan ideological believer in him for me to feel comfortable about his approach.

    The general community has every right to be sceptical and wary of psychiatry’s claims. The profession has not demonstrated it can consistently deliver substantially and unambiguously positive outcomes.

  3. Louise J

    As a clinical psychologist who has worked in the field for more than 20 years I’m very appreciative of this series of articles.

    I totally agree that treatment and prevention programs in this area are historically underfunded in spite of the massive cost to the community of untreated psychological disorders. I am also very pleased, as are most psychologists, that total funding has been increased even though it has been at the expense of services to my own clients under the Better Access Scheme.

    On a few points I would like to differ. Both articles have mentioned “psychologists tearing each other to shreds” – a sensational statement which may have been inferred from comments made in the recent Senate Report. This is not my experience of my profession – even though the two tiered funding has caused division and debate. I’m sure if decisive funding of this nature was imposed on any other profession you would see similar reactions. Most psychologists I know are more concerned with the impact of these changes on the vulnerable people they deal with rather than just lining their own pockets.

    In a similar vein, the tensions and rivalry between the main protagonists could be viewed as typical of spirited academic debate about life and death issues rather than political squabbles over scraps of funding. Psychologists and Psychiatrists do passionately disagree on things; and we are not members of political parties where everyone has to follow the party line. Isn’t vigorous debate a strength rather than a weakness?

    I look forward to the next installment and hope the important issues don’t get sidelined by personality conflict and drama.

  4. Lofi

    McGorry has done more than just step on toes, as unedifying as the spats become. His biggest and potentially most damaging dogma is that of the need to aggressively diagnose psychosis in young people. Apart from the appalling, media/politically driven over-appropriation of money to his pet project, the evidence is NOT in for this kind of approach to youth mental illness. Too-soon diagnosis and pharmacological treatment of teenagers with powerful anti-psychotics is a life-altering decision that should be made based on the advice of a concensus of medical professionals whose conservatism is something to be valued, not denigrated. McGorry has offended these groups with his radical interpretations and media-exploiting ways to get public funds. The consequences for those who subscribe to his philosophy could be very bad, but of course, we won’t know that until it’s too late for these kids. That’s the crime.

  5. Alexander James

    One of the biggest disappointments in this article, of which there are many, is that it was authored by a person with financial and personal links with the people who are the topic of the article. Melissa Sweet has received funding from the Brain and Mind Research Institute (run by Hickie), and she reveals a personal discussion with Hickie’s mother. This is my first reading of Crikey, and really, i had expected a better quality of journalism than a defense of people who she obviously has personal and financial ties with. Hickie has been rightly criticised as he has succeeded in persuading a government that genuinely wants to help that the best way to go is simply to drug people. UK research has demonstrated that after the first 3 months of intervention, it is cheaper for a government to subsidise psychological help than psychiatric drugs. While cutting the publics access to psychologists from 18 to 10 sessions per year, the government now funds 50 visits per year to a psychiatrist- testimony to Hickie’s and McGorry’s persuasive powers. Most of what the majority of psychiatrists do is prescribe drugs- that is what they are equipped to do, whereas psychologists attempt to help people in problem solving and learning new life skills. The links between the pharmaceutical industry and psychiatry are complete- psychiatrists are merely the marketing outlets for drug companies. This is in the absence of any evidence to support the brain theories of mental illness, and even less evidence in support of their brain disabling interventions. McGorry, for his part (also the recipient of drug company funding) has proposed a model of early psychosis intervention which is more science fantasy than reality. International mental health authorities, people who stand to lose nothing financially by this fantasy, state that the false positives are around 7-8 out of 10. These young people will be drugged on the prospect that at some time in the future they may become psychotic, mostly because they have a psychotic parent- and 7-8/10 times they never were going to become psychotic anyway. Antipsychotic drugs cause Tardive Dyskenisia- permanent drug induced brain damage, resulting in Parkinson disease type symptoms. If McGorry gets his way, get used to seeing people in their mid 20’s shuffling and shaking like frail 80 year olds with Parkinsons disease. And this is why the Better Access program (which was clearly demonstrated by research to be a resounding success) has been slashed. More than 80,000 Australians are now going without the psychological services they need so that Hickie and McGorry are able to take us a huge step closer to their Brave New Psychiatric World of better living through drugs, where most of the population is being chemically altered by your friendly neighbourhood psychiatrist. Thanks Hickie and McGorry- the drug companies will be very pleased with your good work. Fortunately, unlike the American population, most Australians are too inherently skeptical to swallow this poison.

  6. ihaywood

    This article is very light on who the critics are and what they are actually saying, other than Jurendini. It’s odd that you largely quote third-parties speculating on the criticism and its motives: why not quote the critics directly?
    You also gloss over (or are underaware??) of the therapeutic differences: Hickie and McGorry largely espouse CBT and medication, the “ancien regime” more oriented to longer-term psychodynamic/attachment-based approaches.

  7. LJG..............

    As a consumer at times of anti-psychotics, the better access program, Lay Drug and Alcohol Programs like AA and NA , ECT and other psychiatric medication some of the things I am most tired and depressed by is:
    1. People who believe that every Mental Illness can be just treated by therapy without the use of medical intervention.
    2. Going to Funerals.

    From the little I know from an undergraduate psychology degree and what I’ve learnt over the years of my illness I realise how little we all know about Mental Illness . Yes treatments don’t always work and yes drugs have side effects and yes years of talking about a problem may not help and cost a lot of money. But we have to keep trying until we learn more.
    Debate is good but Hysteria and misinformation helps no-one.

    And I’m happy to answer any questions about my experiences of any of the above and I don’t have any Parkinson disease type symptoms I’m afraid.

    Regards, Lea.

  8. Thembi Soddell

    Although this article is fairly comprehensive I am just disappointed to not see any consumer opinions represented. I appreciate that this article reflects the sentiment that consumer needs should really be the top priority, but I don’t see how that is going to happen if consumers themselves are not included in the debate – and not just a token one or two, but a comprehensive range that reflect the extremely diverse needs of people living with mental illness and severe psychological distress. I feel like this is a gaping hole in the mental health reform debate and I’m hoping someone will fill it.

  9. Terry Taylor

    I’m a clinical psychologist in private practice in a rural area. The majority of the people I see are bulk-billed under Better Access. In a fact sheet sent to me recently by the Department of Health and Ageing, it was said “It is important that people get the right care for their needs. People who currently receive more than 10 allied mental health services under Better Access are likely to be patients (!) with more complex needs and would be better suited for referral to more appropriate mental health services. GPs can continue to refer those people with more severe ongoing mental disorders to Medicare subsidised consultant psychiatrist services or state/territory specialised mental health services.”

    The above demonstrates a lack of understanding of what the respective services deliver that literally takes my breath away. People who suffer depression, anxiety and all their permutations and combinations need long term treatment to change the habits, beliefs and attitudes of, often, most of their lives. This is, quite simply, what psychologists do. It is not what psychiatrists do, or are trained to do. Psychiatrists have a very necessary place. Yet when I try to refer a client to a psychiatrist for an assessment of their medication it is almost impossible to find someone they can see within any reasonable interval in my rural area.

    The changes to Better Access can only have a deleterious effect to clients with complex needs. It will prevent them from receiving the treatment they need. We have waited so long for an initiative that offers psychological care to those who cannot afford to fund it themselves, and now it is being snatched away.

  10. Chris Mackey

    I think this article misses the main point of concerns about Ian Hickie’s seemingly strongly bias against independent psychological services relative to psychiatry services. It is no secret that many psychiatrists were vehemently opposed to the Better Access scheme from its inception. Ian Hickie in particular has set out to attack the Better Access scheme from the outset. For example in numerous newspaper articles from a short time after the scheme was introduced he attacked the scheme for having no evidence for the effectiveness of services it supported. However, I do not believe that he ever challenged the Medicare-based funding for much more costly private psychiatry services despite these services attracting rebates for more than two decades with no independent evidence for their effectiveness. Such expensive and poorly validated private psychiatry services are still being subsidized for up to 50 sessions per year, seemingly with Ian Hickie’s blessing.

    In a single private practice in Geelong, Chris Mackey and Associates) we have now collected objective outcome data on over 800 adult clients seen through the Better Access scheme (see which we believes exceeds the cumulative total of direct objective evidence for the effectiveness of private psychiatry services by all private psychiatrists in Australia over a period of decades. The official Better Access report by Professor Jane Pirkis and colleagues released in March this year also provides much more evidence than currently exists for the effectiveness of private psychiatry services. So why have Ian Hickie (and Pat McGorry for that matter) not been prepared to challenge funding for private psychiatry services? This seems to represent a blatant form of bias. Our data on over 400 clients shows that the clients we have treated for depressive conditions have recovered just as well regardless of whether or not they were on prescribed medication. We have treated numerous clients effectively who had not responded well to years of prior private psychiatric treatment (especially those with trauma reactions). Cutting such private psychology services, as we have proved to be broadly effective, and seeking to redirect clients requiring more than ten sessions to more costly private psychiatry services, is likely to be a costly mistake. And yet this is what the government is now recommending through its fact sheets on the basis of advice from Ian Hickie, Pat McGorry and other advisors. It seems like blatant bias to me. It is the clients who will miss out. We have objectively demonstrated (see our website) that for those with severe depression, only those who receive more than ten sessions recover to near-normal levels. Many future such clients are likely to miss out following recommendations by Ian Hickie, Pat McGorry and others. I do not believe any current private psychiatry, or public mental health services for that matter, can match the results we have already demonstrated through the Better Access scheme. I have worked in public mental health for 15 years, and there is a marked lack of consistency in expertise. Cutting Better Access is not the answer.